How to objectively measure snoring: a systematic review.

PURPOSE: Snoring is the most common symptom of obstructive sleep apnea. Various objective methods of measuring snoring are available, and even if the measurement is performed the same way, communication is difficult because there are no common reference values between the researcher and clinician with regard to intensity and frequency, among other variables. In other words, no consensus regarding objective measurement has been reached. This study aimed to review the literature related to the objective measurement of snoring, such as measurement devices, definitions, and device locations. METHODS: A literature search based on the PubMed, Cochrane, and Embase databases was conducted from the date of inception to April 5, 2023. Twenty-nine articles were included in this study. Articles that mentioned only the equipment used for measurement and did not include individual details were excluded from the study. RESULTS: Three representative methods for measuring snoring emerged. These include (1) a microphone, which measures snoring sound; (2) piezoelectric sensor, which measures snoring vibration; and (3) nasal transducer, which measures airflow. In addition, recent attempts have been made to measure snoring using smartphones and applications. CONCLUSION: Numerous studies have investigated both obstructive sleep apnea and snoring. However, the objective methods of measuring snoring and snoring-related concepts vary across studies. Consensus in the academic and clinical communities on how to measure and define snoring is required.

Sleep parameter characteristics of patients with OSA who have retropalatal circumferential narrowing and the clinical significance of lateral pharyngeal wall collapse during sleep.

BACKGROUND: The lateral pharyngeal wall (LPW) is a critical anatomic structure in patients with obstructive sleep apnea (OSA). Resolving the retropalatal circumferential (RC) narrowing caused by combination of both LPW collapse and antero-posterior (AP) narrowing holds promise for surgical treatment of OSA. We sought to determine the clinical characteristics and distinctive alterations in sleep parameters of patients with OSA who have RC narrowing and LPW collapse. METHODS: Drug-induced sleep endoscopy (DISE), polysomnography findings, and sleep questionnaires were reviewed retrospectively in patients with OSA. RESULTS: Of the 106 OSA patients examined, 48% showed RC narrowing and 44% showed AP narrowing at the oropharynx level during sleep while 8% of the patients showed only LPW collapse. Patients with RC narrowing with LPW collapse exhibited a higher BMI than those with AP narrowing only. In addition, patients with RC narrowing showed more aggravated sleep parameters including apneic events than patients with AP narrowing alone. The degree of RC narrowing correlated significantly with the severity of OSA as shown by a higher apnea index and lower oxygen desaturations. CONCLUSIONS: Our clinical findings suggest that the presence of RC narrowing with LPW collapse in OSA is closely related to increased apneic and oxygen desaturation events. RC narrowing with LPW collapse may be targets for surgical correction in patients with OSA to improve therapeutic outcomes.

Investigating factors influencing post-operative growth in pre-pubertal children after adenotonsillectomy.

PURPOSE: To check the change in growth-for-age after adenotonsillectomy in pre-pubertal children and investigate the affecting factors. METHODS: Two hundred and six pediatric patients who underwent adenotonsillectomy by a single surgeon between January 2011 and December 2014 were included for the retrospective cohort study. The z-scores of height-, weight-, and body mass index (BMI)-for-age were measured before adenotonsillectomy and 1 year after the operation. The Korean version of the obstructive sleep apnea-18 questionnaire (OSA-18), symptom questionnaire, physical examinations, demographic data, and pre-operative z-scores were used to analyze the factors affecting z-score change. RESULTS: Among 206 pediatric patients, 167 patients were normal growth; 19 were undergrowth; and 20 were obese. After the operation, height, weight, and BMI z-scores all increased both in 167 normal-growth patients and 19 undergrowth patients (p value < 0.05). However, in 20 obese patients, only height z-score significantly increased (p value = 0.028). The multiple regression test showed that the sleep disturbance domain of OSA-18 was positively correlated with height z-score change (p value = 0.041), and age was negatively correlated with weight z-score change (p value = 0.016). Pre-operative BMI z-score was negatively correlated (p value = 0.019) and adenoid grade was positively correlated (p value = 0.023) with BMI z-score change. CONCLUSIONS: These findings suggest that adenotonsillectomy may positively affect growth in pre-pubertal children, without undesirable weight gain. Additionally, the sleep disturbance domain of OSA-18 may play a role in predicting post-operative height increase in pre-pubertal children.

DEP-induced ZEB2 promotes nasal polyp formation via epithelial-to-mesenchymal transition.

BACKGROUND: Diesel exhaust particles (DEPs) are associated with the prevalence and exacerbation of allergic respiratory diseases, including allergic rhinitis and allergic asthma. However, DEP-induced mechanistic pathways promoting upper airway disease and their clinical implications remain unclear. OBJECTIVE: We sought to investigate the mechanisms by which DEP exposure contributes to nasal polyposis using human-derived epithelial cells and a murine nasal polyp (NP) model. METHODS: Gene set enrichment and weighted gene coexpression network analyses were performed. Cytotoxicity, epithelial-to-mesenchymal transition (EMT) markers, and nasal polyposis were assessed. Effects of DEP exposure on EMT were determined using epithelial cells from normal people or patients with chronic rhinosinusitis with or without NPs. BALB/c mice were exposed to DEP through either a nose-only exposure system or nasal instillation, with or without house dust mite, followed by zinc finger E-box-binding homeobox (ZEB)2 small hairpin RNA delivery. RESULTS: Bioinformatics analyses revealed that DEP exposure triggered EMT features in airway epithelial cells. Similarly, DEP-exposed human nasal epithelial cells exhibited EMT characteristics, which were dependent on ZEB2 expression. Human nasal epithelial cells derived from patients with chronic rhinosinusitis presented more prominent EMT features after DEP treatment, when compared with those from control subjects and patients with NPs. Coexposure to DEP and house dust mite synergistically increased the number of NPs, epithelial disruptions, and ZEB2 expression. Most importantly, ZEB2 inhibition prevented DEP-induced EMT, thereby alleviating NP formation in mice. CONCLUSIONS: Our data show that DEP facilitated NP formation, possibly via the promotion of ZEB2-induced EMT. ZEB2 may be a therapeutic target for DEP-induced epithelial damage and related airway diseases, including NPs.

Optimal application of soft-palate webbing flap pharyngoplasty combined with nasal surgery for surgical treatment of primary snoring and obstructive sleep apnea.

BACKGROUND: Excessive collapse of the soft palate and lateral pharyngeal wall narrowing are established causes of loud snoring and sleep apnea in subjects with obstructive sleep apnea (OSA). Therefore, delicate surgical techniques are needed to reshape the soft palate and create sufficient tension in the lateral pharyngeal wall. This study aimed to determine the therapeutic outcome and favorable indications of soft-palate webbing flap pharyngoplasty in subjects with OSA and primary snoring. METHODS: A total of 174 subjects who underwent soft-palate webbing flap pharyngoplasty combined with uvulopalatal flap and septoturbinoplasty from August 2015 to February 2020 were included in this study. Medical records, including pre- and postoperative sleep parameters, were retrospectively reviewed. The primary outcome measure was the degree of improvement in AHI after surgery. Other outcomes were differences in surgical response rates, subjective visual analog score (VAS) for snoring, sleep quality, and complications. RESULTS: Polysomnographic results showed that apnea-hypopnea index (AHI) scores were significantly reduced from 39.6 ± 6.1 to 22.9 ± 3.6 following soft-palate webbing flap pharyngoplasty in 59 subjects, and overall success and response rates of this technique were analyzed with 71%. We found that the successful outcomes were observed in 50% of mild (n = 12) and 56% of moderate (n = 16) subjects with OSA subjects due to lateral pharyngeal wall collapse. The success rate of soft-palate webbing flap pharyngoplasty was relatively higher in subjects with mild and moderate OSA than those with severe OSA. Additionally, the mean VAS snoring scale was 4.7 and subjects' primary snoring intensity significantly improved to 2.9 after soft-palate webbing flap pharyngoplasty. Subjective symptoms such as daytime sleepiness and sleep quality also showed improvement. Most complications were found to be minimal and improved by 1 month after the operation. CONCLUSION: Our data demonstrate that soft-palate webbing flap pharyngoplasty is an effective treatment for OSA and primary snoring and may be a promising technique to reduce lateral pharyngeal wall collapse.

Correlation of site of obstruction between two dynamic evaluation modalities in obstructive sleep apnea patients: drug-induced sleep endoscopy and sleep videofluoroscopy.

PURPOSE: Drug-induced sleep endoscopy (DISE) and sleep videofluoroscopy (SVF) are two dynamic modalities for evaluating the upper airway in patients with obstructive sleep apnea (OSA). We evaluated the correlation of obstructive sites determined by DISE and SVF in OSA patients and elucidate findings that can improve the accuracy of upper airway assessment. METHODS: A consecutive series of 63 patients with OSA who underwent DISE and SVF were the subjects of this study. The DISE and SVF findings were divided according to the anatomical structure responsible for the collapse, including the soft palate (SP), oropharyngeal lateral walls (LW), tongue base (TB), and larynx (LX). The obstruction was graded on the three-point scale: 0, no obstruction; 1, partial obstruction; or 2, complete obstruction. Additionally, grade 1.5 TB obstruction was designated when the posterior displacement of the anterior tongue was detected during simultaneous retropalatal obstruction. The agreement rate and Cohen's kappa test between the two modalities were also assessed. RESULTS: The agreement rate between the two modalities was highest in LX (88.9%) followed by SP (85.7%), TB (76.1%), and LW (74.6%) (Cohen's kappa value = 0.757 in LX, 0.642 in SP, 0.637 in TB, 0.612 in LW, respectively). When grade 1.5 and 2 TB obstructions were combined, the agreement rate increased to 88.9% (Cohen's kappa value = 0.757). CONCLUSIONS: We found a good overall agreement between the two dynamic airway evaluation modalities during drug-induced sleep, and this correlation may be improved if the posterior displacement of the anterior tongue during DISE is used as a sign of TB obstruction.

Clinical characteristics of asymptomatic allergen sensitization with nasal septal deviation, often misdiagnosed as allergic rhinitis.

PURPOSE: Allergic rhinitis (AR) is often defined based on symptoms accompanied by a positive allergen sensitivity test result. However, a positive skin prick test (SPT) does not always imply the occurrence of clinical symptoms. If an asymptomatic allergen-sensitized patient has nasal septal deviation (DSN) that could cause nasal obstruction, the condition could easily be confused with typical symptomatic AR. This study investigated the clinical and laboratory characteristics of asymptomatic allergen-sensitization with septal deviation (ASSD). METHODS: Patients from a nationwide AR cohort study, conducted in 8 university hospitals, were investigated. AR was diagnosed when there were at least 1 rhinitis symptom with a positive SPT result. The ASSD group included patients who had severe nasal obstruction with few other symptoms and a positive SPT, along with septal deviation. Clinical and laboratory characteristics were compared between the ASSD group and the true AR group. RESULTS: In total, 728 patients were included. The average age was 32.2 ± 12.7 and 66% of the patients had DSN. SPT indicated that ASSD patients were less sensitized to house dust mite (p = 0.019 for Dp and p = 0.021 for Df). There was a significant sex difference: the male-to-female ratio was higher in the ASSD than in the AR group (3.59 vs. 1.77, p = 0.012). However, no statistically significant differences in age, family history, and body mass index were found. CONCLUSION: ASSD can mimic AR. When dealing with allergen-sensitized patients with a predominant symptom of nasal obstruction, DSN might also be considered before confirming a diagnosis of AR.

Efficacy and safety of rupatadine fumarate in the treatment of perennial allergic rhinitis: A multicenter, double-blinded, randomized, placebo-controlled, bridging study in Koreans.

BACKGROUND: The efficacy of rupatadine for the treatment of AR has been confirmed in numerous clinical studies, however there are very few studies on asian patients. OBJECTIVE: To assess the safety and efficacy of rupatadine fumarate in the treatment of Korean perennial allergic rhinitis (PAR) patients. METHODS: A multicenter, double-blind, randomized, placebo-controlled, comparative study of rupatadine fumarate and bepotastine besilate was conducted. Each group was administered rupatadine, bepotastine or placebo for 4 weeks. Primary parameters for efficacy included morning and evening symptom reduction from baseline at 4 weeks. Treatment safety and tolerability were evaluated according to a self-reported incidence and type of adverse events at each follow up visit. RESULTS: Rupatadine showed a significant reduction in symptoms at morning and evening evaluations, in both 5TSS (-5.69, P < 0.0006) and 4NTSS (-4.74, P < 0.0015) compared to placebo. There was a significant reduction from baseline for 5TSS (-65.4%, P = 0.002) and 4NTSS (-63.7%, P = 0.003) with rupatadine compared with placebo. At evening evaluations, there were significant reductions of 5TSS (-63.2%, P = 0.009) and 4NTSS (-61.6%, P = 0.013) for the rupatadine group. Compared with bepotastine, rupatadine showed greater reduction in the morning symptoms at 4 weeks. When individual symptoms were assessed with 12-hour reflective mean daily symptom score, rupatadine showed better efficacy than placebo in sneezing (P = 0.016) and rhinorrhea (P = 0.097). The rate of adverse events showed no statistical significance. CONCLUSIONS: Rupatadine is a safe and effective treatment option for Korean PAR patients and possibly a better choice over bepotastine for controlling morning symptom.

Age-associated changes in chronic rhinosinusitis endotypes.

BACKGROUND: Immunologic function in innate and adaptive immunity changes with the ageing process. Thus, age-related cytokine profiles in chronic rhinosinusitis (CRS) need to be investigated for precision medicine. OBJECTIVE: The objective of this study was to characterize age-related changes in immunologic profiles according to CRS subtypes. METHODS: Subjects in control (n = 29), CRS without nasal polyps (CRSsNP, n = 86), and CRS with nasal polyps (eosinophilic NP: ENP, n = 81; non-eosinophilic NP: NENP, n = 113) were enrolled in this study. Twenty markers for type 1/2/3 inflammation and other inflammatory processes were measured in homogenates of sinonasal tissues and statistically analysed. RESULTS: In control tissues, type 2/3 and proinflammatory mediators showed an inverse correlation with age. CRSsNP and NENP showed an age-related increase in type 2 cytokines and a decline in type 3 cytokines. Interestingly, the age-related decrease in type 3 mediators was associated with those of CT scores in NENP. ENP showed an age-related increase in type 3 cytokines with type 2 mediators sustained at high levels. Smokers with ENP demonstrated age-associated increases in type 1/2/3 mediators as well as CT scores. These age-related patterns in each CRS were confirmed by statistically adjusting atopy status, smoking history, and disease duration. CONCLUSION: Age-associated cytokine changes differed among CRS subtypes and control tissues. CRSsNP and NENP demonstrated a decline in type 3 mediators and increase in type 2 mediators, whereas type 3 mediators increased with age in ENP.

Intranasal delivery of Duox2 DNA using cationic polymer can prevent acute influenza A viral infection in vivo lung.

We studied the contribution of Duox2 in mucosal host defense against influenza A virus (IAV) infection in in vivo lung. We found that Duox2 was required for the induction of type I and III interferon (IFN)s and transient Duox2 overexpression using cationic polymer polyethyleneimine (PEI) leads to suppression of IAV infection in in vivo lung. Twenty mice (C57BL/6J) were anesthetized and challenged by intranasal administration of 213 pfu/30 µl of IAV (WS/33/H1N1), and IAV-infected mice were euthanized at 1, 3, 5, 7, 10, 14 days post infection (dpi). Duox2 small hairpin RNA (shRNA) and pCMV-Duox2 formulated with PEI were inoculated to mice to assess the regulatory mechanism between Duox2 and IFN secretion. Following intranasal IAV inoculation, viral infection was significantly aggravated from 3 dpi in in vivo lung and viral titer was highest at 7 dpi. Consistent with this, Duox2 messenger RNA (mRNA) and protein expressions were significantly induced from 3 dpi in the lung tissue of IAV-infected mice. Viral titer was much higher in IAV-infected mice that were inoculated with Duox2 shRNA accompanied with lower survival rate and extensive lung pathologies. Interestingly, severe lung pathologies in IAV-infected mice were not observed and viral titer was significantly reduced in mice with pulmonary administration of pCMV-Duox2 formulated with PEI before IAV inoculation. Both mRNA and secreted protein levels of IFN-ß and IFN-λ2/3 were highly elevated in IAV-infected mice with pCMV-Duox2 formulated with PEI. Duox2 is necessary for the regulation of IFN secretion in in vivo lung, and pulmonary administration of Duox2 DNA using cationic polymer triggers the induction of type I and III IFNs resulting in more complete suppression of IAV infection.

Evaluation of the success of obstructive sleep apnea surgery using criteria based on long-term symptoms and incident hypertension.

OBJECTIVE: To identify appropriate success criteria, based on long-term symptoms and incident hypertension, after surgery for obstructive sleep apnea (OSA). METHODS: This observational cohort study included 97 adult OSA patients (90 men) who underwent surgical treatment at our tertiary medical center. Subjective symptoms [witnessed sleep apnea and snoring, and Epworth sleepiness scale (ESS) scores] were evaluated through a telephone survey, and incident hypertension was assessed from medical records. The subjects were divided into success and failure groups according to seven different criteria, and data were analyzed to identify the criteria that could significantly differentiate the success from failure groups. RESULTS: The participants had a mean age of 48.8 ± 11.9 years and a mean preoperative body mass index of 26.5 ± 3.5 kg/m2. The mean preoperative and postoperative apnea-hypopnea index (AHI) values were 36.1/h and 19.4/h, respectively. The mean follow-up duration was 77.0 ± 31.1 months. Postoperative witnessed apnea, snoring, and the ESS scores decreased significantly compared to preoperative scores in both the success and failure groups based on most of the seven criteria. Among the seven criteria, success and failure groups based on a postoperative AHI cutoff of 15 or 20/h differed significantly in witnessed apnea, snoring, or ESS scores. Kaplan-Meier survival analysis based on incident hypertension revealed that no criterion could significantly distinguish between the two groups. CONCLUSIONS: Our results suggest that some of the success criteria analyzed may be more useful in differentiating between success and failure groups after surgery, in terms of long-term improvement of subjective OSA-related symptoms.

Soft palate cephalometric changes with a mandibular advancement device may be associated with polysomnographic improvement in obstructive sleep apnea.

PURPOSE: It is unclear whether soft palate-associated changes in cephalometry associated with a mandibular advancement device (MAD) are independently associated with improvements in polysomnography (PSG) respiratory parameters in obstructive sleep apnea (OSA). METHODS: This retrospective review aimed to identify the association between soft palate-associated changes in cephalometry and PSG changes after application of an MAD. Korean patients diagnosed with OSA who underwent cephalometry with or without an MAD were enrolled. All the patients were evaluated after undergoing full-night PSG twice: once with an MAD and once without. Cephalometric findings were measured using an image analyzer. RESULTS: Mean apnea-hypopnea index significantly decreased with an MAD from 36.4/h to 14.7/h (p < 0.001). Retropalatal airway space significantly increased with an MAD from 6.6 to 7.3 mm (p = 0.013). Soft palate length also significantly decreased with an MAD from 43.6 to 42.3 mm (p = 0.02). Although these findings were shown by responders (patients with a reduction of apnea-hypopnea index by more than 50%), there were no significant changes in non-responders. However, retroglossal airway space did not significantly increase with an MAD even in responders. CONCLUSIONS: Improvement of OSA with an MAD can be predicted with soft palate-associated upper airway changes shown in cephalometry.

The Superiority of IFN-λ as a Therapeutic Candidate to Control Acute Influenza Viral Lung Infection.

Here, we studied the IFN-regulated innate immune response against influenza A virus (IAV) infection in the mouse lung and the therapeutic effect of IFN-λ2/3 in acute IAV lung infection. For viral infections, IAV (WS/33, H1N1, PR8 H1N1, H5N1) were inoculated into wild-type mice by intranasal delivery, and IAV mRNA level and viral titer were measured. To compare the antiviral effect of IFNs in vivo in the lung, neutralizing antibodies and recombinant IFNs were used. After intranasal inoculation of IAV into mice, viral infection peaked at 7 days postinfection, and the IAV titer also reached its peak at this time. We found that IFN-ß and IFN-λ2/3 were preferentially induced after IAV infection and the IFN-λ2/3-mediated innate immune response was specifically required for the induction of IFN-stimulated genes (ISGs) transcription in the mouse respiratory tract. Neutralization of secreted IFN-λ2/3 aggravated acute IAV lung infection in mice with intact IFN-ß induction; consistent with this finding, the transcription of ISGs was significantly reduced. Intranasal administration of IFN-λ2/3 significantly suppressed various strains of IAV infection, including WS/33 (H1N1), PR (H1N1), and H5N1 in the mouse lung, and was accompanied by greater up-regulation of ISGs. Taken together, our data indicate that the IFN-λ2/3-mediated innate immune response is necessary to protect the lungs from IAV infection, and intranasally delivered IFN-λ2/3 has the potential to be a useful therapeutic strategy for treating acute IAV lung infection.

Chronic rhinosinusitis with nasal polyps is associated with chronic otitis media in the elderly.

Chronic rhinosinusitis (CRS) and chronic otitis media (COM) are common diseases in the otorhinolaryngology field. Although clinicians frequently encounter patients presenting both diseases simultaneously, a few studies have shown relationships between them. We examined whether CRS was associated with COM in adults who participated in the Korea National Health and Nutrition Examination Survey from 2009 to 2012. A total of 27,492 participants were examined in this cross-sectional epidemiological study. Regression analyses was performed and adjusted for socio-demographics, general health behavior, and other comorbidities. All analyses used complex sampling designs; subgroup analyses were performed according to age, hearing loss, and the presence of cholesteatoma or nasal polyps. The weighted prevalence of COM and CRS was 3.6 ± 0.2 and 6.0 ± 0.2%, respectively. COM prevalence was significantly higher in subjects with CRS (5.1%) than in those without (3.5%). In the multivariate analysis, COM was more prevalent in subjects with CRS (adjusted odds ratio = 1.738; P = 0.038) after adjusting for other factors. The subgroup analysis showed that this association was significant only in older subjects (≥50 years) with nasal polyps. Non-serviceable hearing and cholesteatoma were not significantly associated with CRS. Our findings demonstrated that CRS with nasal polyps might be associated with COM in older patients.

Sirtuin 1 attenuates nasal polypogenesis by suppressing epithelial-to-mesenchymal transition.

BACKGROUND: Nasal polyps (NPs) imply a refractory clinical course in patients with chronic rhinosinusitis (CRS). Previously, we showed that hypoxia-inducible factor (HIF) 1 could mediate nasal polypogenesis through epithelial-to-mesenchymal transition (EMT). Sirtuin 1 (SIRT1), a histone deacetylase, reportedly suppresses the transcriptional activity of HIF-1. Thus we hypothesized that SIRT1 attenuates nasal polyposis by inhibiting HIF-1-induced EMT. OBJECTIVE: We sought to determine the role of SIRT1 in patients with nasal polyposis. METHODS: The effects of SIRT1 on nasal polypogenesis were investigated in previously developed murine models. Immunohistochemistry, immunoblotting, and immunoprecipitation were done to evaluate SIRT1, EMT, and hypoxic markers in human nasal epithelial cells or sinonasal tissues from the mice and the patients with CRS with or without NPs. RESULTS: SIRT1 transgenic mice had significantly fewer mucosal lesions with epithelial disruption and fewer NPs than wild-type (WT) mice. In addition, resveratrol (a SIRT1 activator) treatment suppressed nasal polypogenesis in WT mice; however, sirtinol (a SIRT1 inhibitor) administration increased the polyp burden in SIRT1 transgenic mice. In sinonasal specimens from patients with CRS, SIRT1 was downregulated in the mucosa from patients with polyps compared with levels seen in patients without polyps. SIRT1 overexpression or activation reversed hypoxia-induced EMT in human nasal epithelial cells. The intranasal transfection of a small hairpin SIRT1 lentiviral vector induced more nasal polypoid lesions in SIRT1 transgenic mice. Finally, mucosal extracts from patients with CRS without NPs increased SIRT1 expression in nasal epithelial cells, whereas those from patients with CRS with NPs did not. CONCLUSION: SIRT1 suppressed NP formation, possibly because of inhibition of HIF-1-induced EMT. Thus nasal epithelium SIRT1 might be a therapeutic target for NPs.

Erythrocyte sedimentation rate may help predict severity of obstructive sleep apnea.

PURPOSE: Previous studies have shown a relationship between obstructive sleep apnea (OSA) and erythrocyte sedimentation rate (ESR), a representative marker for inflammation. We aimed to elucidate the possible association between elevated ESR and OSA severity. METHODS: A total of 341 patients who visited a sleep center were retrospectively enrolled. Subjects underwent physical examination, overnight polysomnography (PSG), and blood sampling for ESR and high-sensitivity C-reactive protein (hs-CRP). We compared the ESR and hs-CRP level to OSA severity and measured their correlation with other PSG parameters. RESULTS: The ESR was significantly higher in patients with severe OSA (apnea-hypopnea index (AHI) ≥ 30) than those with simple snoring (AHI < 5; P = 0.016), mild OSA (5 ≤ AHI < 15; P = 0.010), and moderate OSA (15 ≤ AHI < 30; P = 0.042). Similarly, the hs-CRP level in patients with severe OSA was significantly higher than that in patients with simple snoring (P = 0.006) and mild OSA (P = 0.013). Multivariate analysis also showed that elevated ESR was associated with moderate and severe OSA (adjusted OR = 2.231 (P = 0.048) and 2.606 (P = 0.002), respectively) after adjusting for sex, age, body mass index, smoking, hypertension, diabetes mellitus, and hyperlipidemia. However, elevated hs-CRP was not associated with the OSA severity. CONCLUSIONS: ESR more closely correlated with PSG parameters recorded during sleep hypoxic episodes than hs-CRP. Moreover, the ESR may be useful to predict the OSA severity because moderate and severe OSA were independently associated with an elevated ESR.

Adenotonsillar hypertrophy as a risk factor of dentofacial abnormality in Korean children.

No studies for the role of adenotonsillar hypertrophy in development of dentofacial abnormalities have been performed in Asian pediatric population. Thus, we aimed to investigate the relationship between adenotonsillar hypertrophy and dentofacial abnormalities in Korean children. The present study included consecutive children who visited a pediatric clinic for sleep-disordered breathing due to habitual mouth breathing, snoring or sleep apnea. Their palatine tonsils and adenoids were graded by oropharyngeal endoscopy and lateral cephalometry. Anterior open bite, posterior crossbite, and Angle's class malocclusions were evaluated for dentofacial abnormality. The receiver-operating characteristic curve analysis was used to identify age cutoffs to predict dentofacial abnormality. A total of 1,083 children were included. The presence of adenotonsillar hypertrophy was significantly correlated with the prevalence of dentofacial abnormality [adjusted odds ratio = 4.587, 95% CI (2.747-7.658)] after adjusting age, sex, body mass index, allergy, and Korean version of obstructive sleep apnea-18 score. The cutoff age associated with dentofacial abnormality was 5.5 years (sensitivity = 75.5%, specificity = 67%) in the children with adenotonsillar hypertrophy and 6.5 years (sensitivity = 70.6%, specificity = 57%) in those without adenotonsillar hypertrophy. In conclusion, adenotonsillar hypertrophy may be a risk factor for dentofacial abnormalities in Korean children and early surgical intervention could be considered with regards to dentofacial abnormality.

Evaluation of coblation lingual tonsil removal technique for obstructive sleep apnea in Asians: preliminary results of surgical morbidity and prognosticators.

Retroglossal obstruction is one of the etiologies causing obstructive sleep apnea (OSA) and can be addressed by removing some tissues of the tongue base. However, because of its deep-seated location, its surgical removal is still challenging. Although coblation technique has been introduced, its efficacy and morbidity need further evaluation, particularly in Asians. This study aimed to assess its safety and effectiveness and to identify outcome prognosticators. Forty-seven OSA patients who underwent coblation lingual tonsil removal were included. Retroglossal obstruction was confirmed by drug-induced sleep videofluoroscopy. Attended full-night polysomnography was performed twice; before and 6 months after surgery in 27 patients. The tongue base was fully exposed with three deep-seated traction sutures, visualized with a 30° or 70° endoscope, and ablated using a coblator. Surgical success was defined with postoperative apnea hypopnea index (AHI) <20 and reduction >50 %. Postoperative morbidities were evaluated. Demographic and polysomnographic parameters between success and failure groups were compared. None of the patients had immediate postoperative hemorrhage. Postoperatively, one patient had delayed hemorrhage and one patient severe respiratory difficulty. Taste loss, tongue dysmotility, dental injury or severe oropharyngeal stricture were absent. A mean AHI decreased from 37.7 ± 18.6 to 18.7 ± 14.8/h (P < 0.001). The success rate was 55.6 %. Their mean minimal oxygen saturation was significantly lower (P = 0.004) in the failure group. Coblation lingual tonsil removal technique showed minimal morbidity and favorable outcome in Koreans. The surgical outcome might be associated with the severity of single respiratory events.

Influencing factors on the effect of mandibular advancement device in obstructive sleep apnea patients: analysis on cephalometric and polysomnographic parameters.

BACKGROUND: The purposes of this study were to evaluate clinical outcome of mandibular advancement device (MAD) for obstructive sleep apnea (OSA) patients and to estimate influencing factors on MAD effect. METHODS: From the patients who were diagnosed as OSA by polysomnography at Seoul National University Bundang Hospital from January 2007 to February 2009, the patients who chose MAD as initial treatment option were included. All the patients' data were collected by reviewing and analyzing medical record and radiograph retrospectively. RESULTS: Eighty-six patients (76 males and 10 females; mean age of 51.5 ± 9.8 years) with OSA were included in this study. Total success rate of MAD treatment was 47.7% (41/86 patients). Among cephalometric parameters, lower facial height (35.61 ± 4.26 vs. 38.19 ± 4.89) showed significant difference between success group and non-success group. From the polysomnographic parameters, apnea index (19.79 ± 17.32 vs. 30.08 ± 23.28), average oxygen saturation (95.03 ± 1.42 vs. 94.32 ± 1.56), lowest oxygen saturation (81.44 ± 6.64 vs. 76.87 ± 7.98), oxygen saturation under 90% (4.47 ± 5.90 vs. 9.01 ± 9.29), and oxygen desaturation index (23.58 ± 17.46 vs. 37.16 ± 22.35) showed significant difference between groups. CONCLUSIONS: From the results, it was proved that MAD was an effective treatment option for the OSA patients. Some cephalometric and polysomnographic parameters including posterior lower facial height, apnea index, average oxygen saturation, lowest oxygen saturation, oxygen saturation under 90 %, and oxygen desaturation index could be influencing factors on MAD effect.

Cardiopulmonary coupling analysis: changes before and after treatment with a mandibular advancement device.

PURPOSE: The aim of this study is to evaluate the changes of sleep quality in patients using a mandibular advancement device (MAD) for obstructive sleep apnea (OSA) based upon cardiopulmonary coupling (CPC). METHODS: A total of 52 patients (mean age 53.7±9.6 years, range 33-74 years) were included in this study. Of them, there were 47 males (90.4%). All subjects were diagnosed with OSA after in-laboratory full-night polysomnography and reevaluated after 3-month use of a MAD. At baseline, apnea-hypopnea index (AHI) was 33.6±17.0, Epworth sleepiness scale was 10.5±4.8, and Pittsburgh sleep quality index was 5.8±2.8. The CPC parameters were extracted from single-lead electrocardiography of polysomnography. We compared CPC parameters at baseline with those after 3-month use of a MAD. RESULTS: All respiratory indices improved with the use of MAD. However, there were no differences in the sleep architectures except N3 sleep (3.7±4.3 to 6.9±6.4%, p<0.001). The CPC parameters showed a significant improvement with the use of MAD. Low-frequency coupling (59.5±16.1 to 47.7±14.8%, p<0.001) and elevated low-frequency coupling (44.6±18.4 to 32.6±15.7%, p<0.001) significantly decreased. High-frequency coupling (28.6±16.0 to 36.5±15.7%, p=0.004) and very low frequency coupling (11.7±7.2 to 15.3±6.6%, p=0.028) significantly increased. The change of AHI significantly correlated with changes of the CPC parameters: negatively correlated with high-frequency coupling change (r=-0.572, p<0.001) and positively correlated with low-frequency and elevated low-frequency coupling changes (r=0.604 and 0.497, respectively; p<0.001 in both). However, the changes of Epworth sleepiness scale and Pittsburgh sleep quality index after MAD therapy showed no significant correlation with the changes in the CPC parameters. CONCLUSIONS: To our knowledge, this is the first study to evaluate the quality of sleep in patients using a MAD for their OSA based upon CPC analysis. Low-frequency coupling decreased as AHI improved, while high-frequency coupling increased as AHI improved. The CPC parameters showed that the sleep quality was improved by MAD therapy.